Sonography in Testicular Trauma and Conditions

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Questions and Answers

What are the possible sonographic appearances of a hematocele over time?

Always anechoic, with the appearance not changing over time

Always echogenic, with the appearance not changing over time

Initially anechoic with low-level echoes that can be seen to float or move in real time, later becoming echogenic with fluid-fluid levels or septations

Initially echogenic with numerous, highly visible echoes that can be seen to float or move in real time, later showing low-level echoes and developing fluid-fluid levels or septations (correct)

What is a common characteristic of acute scrotal trauma?

Pain and swelling (correct)

Absence of bruising

Absence of discoloration

Absence of pain and swelling

Which of the following is NOT a sonographic finding associated with scrotal rupture?

Interruption of tunica albuginea

Blood flow disruption across surface of testis

Focal alteration of testicular parenchymal pattern

Absence of scrotal wall thickening (correct)

What is the time limit for surgery following a testicular injury to maximize the chances of saving the testis?

72 hours (B) Signup and view all the answers

What sonographic appearance is characteristic of hematomas associated with scrotal trauma?

Heterogeneous, with cystic components (D) Signup and view all the answers

What is the most likely sonographic finding in a cryptorchid testicle?

Smaller and less echogenic than the normal testis (A) Signup and view all the answers

What is the typical sonographic appearance of a normal testicle?

Oval with a homogeneous texture and a rarely seen mediastinum (B) Signup and view all the answers

What does "hypoechoic" refer to in the context of sonographic findings?

An area that appears darker than surrounding tissues (A) Signup and view all the answers

Which of the following statements is TRUE regarding the mediastinum of a cryptorchid testicle?

It is rarely seen due to the smaller size of the testicle (C) Signup and view all the answers

A sonographic exam reveals an undescended left testicle. What is the most likely finding in the right testicle?

Normal in appearance (C) Signup and view all the answers

What is the most common cause of correctible male infertility?

Varicocele (B) Signup and view all the answers

Which of the following is NOT a sonographic finding of varicocele?

Increased flow and diameter in response to Valsalva maneuver (C) Signup and view all the answers

Which of the following is a characteristic of secondary varicocele?

Increased pressure in the spermatic vein (A) Signup and view all the answers

What is the sonographic appearance of epididymitis?

Enlarged, hypoechoic, with hyperemic flow confirmed with color Doppler (D) Signup and view all the answers

Which of the following is a clinical symptom of scrotal inflammation?

Dysuria (B) Signup and view all the answers

Which of the following is a characteristic of primary varicocele?

Incompetent venous valves of the spermatic vein (D) Signup and view all the answers

What is a possible clinical manifestation of varicocele?

Possible infertility (C) Signup and view all the answers

What is the most common cause of acute testicular pain in adults?

Epididymitis (A) Signup and view all the answers

What is the most common cause of epididymo-orchitis?

Spread of lower urinary tract infection via the spermatic cord (C) Signup and view all the answers

Which of the following sonographic findings is typical of epididymo-orchitis?

Hypoechoic testicle with increased vascularity (B) Signup and view all the answers

What is a pyocele?

A collection of pus in the tunica vaginalis (D) Signup and view all the answers

What sonographic finding is associated with testicular infarction in orchitis?

Swollen testicle confined within a rigid tunica albuginea (D) Signup and view all the answers

Which of these types of testicular masses is considered malignant until proven otherwise?

Intratesticular masses (C) Signup and view all the answers

What sonographic finding is characteristic of microlithiasis?

Multiple small calcifications (<3 mm) within the testicle (B) Signup and view all the answers

Which of the following is NOT associated with microlithiasis?

Benign prostatic hyperplasia (A) Signup and view all the answers

Which of the following is NOT a common sonographic appearance of an adrenal rest within the testicle?

Solid, hypoechoic intratesticular mass (D) Signup and view all the answers

Which of the following is a clinical manifestation of a seminoma?

Hardening of the testicle (D) Signup and view all the answers

What is the sonographic appearance of a scrotal cyst?

Hypoechoic, well-defined, round or oval structure (A) Signup and view all the answers

Which of the following is the most likely cause of decreased blood flow to the affected testicle in epididymo-orchitis?

All of the above (D) Signup and view all the answers

What is the most common type of malignancy affecting the testicles?

Seminoma (B) Signup and view all the answers

Which of the following is a type of germ cell tumor?

Teratoma (B) Signup and view all the answers

What is the typical age range for testicular cancer to occur?

20-34 years old (D) Signup and view all the answers

Which of the following is a potential sonographic finding associated with a teratoma?

Heterogenous mass with calcifications (C) Signup and view all the answers

Which of the following is a common finding associated with vasectomy?

None of the above (D) Signup and view all the answers

Which tumor is associated with elevated levels of both AFP and hCG?

Embryonal cell carcinoma (B) Signup and view all the answers

What is the common sonographic appearance of a yolk sac tumor?

Heterogenous mass with areas of hemorrhage and calcifications (A) Signup and view all the answers

Choriocarcinoma typically presents with which clinical symptom?

Elevated hCG (C) Signup and view all the answers

Which of the following tumors is known for having a favorable prognosis?

Yolk sac tumor (C) Signup and view all the answers

Which non-germ cell tumor may lead to gynecomastia due to estrogen production?

Sertoli cell tumor (A) Signup and view all the answers

Which tumor is characterized by irregular borders and a mixed sonographic appearance due to varying cell types?

Choriocarcinoma (B) Signup and view all the answers

Which of the following non-germ cell tumors is most commonly found in men over the age of 60?

Lymphoma (A) Signup and view all the answers

Which tumor is characterized by hypoechoic appearance and potentially cystic areas?

Leydig cell tumor (B) Signup and view all the answers

Study Notes

Cryptorchidism

Undescended testicles are smaller and less echogenic than normal testicles.
Undescended testicles are typically oval with a homogeneous texture.
The mediastinum is rarely seen in sonograms of undescended testicles.

Testicular Ectopia

Ectopic testicles can't be moved to the correct scrotal position.
The most common location for ectopic testicle placement is the superficial inguinal pouch.
Other potential locations include the perineum, femoral canal, suprapubic area, penis, diaphragm, and other scrotal compartments.

Anorchia

Unilateral anorchia (monorchidism) is found in 4% of patients with nonpalpable testis.
Anorchia is more common on the left side.
Definitive diagnosis relies on surgical evaluation.
Causes include intrauterine testicular torsion or other decreased vascular supply to the testicle in utero.

Polyorchidism (Testicular Duplication)

An extremely rare condition.
The left side is more commonly affected (75%).
Bilateral cases are present in 5% of cases.
Associated conditions include malignancy, cryptorchidism, inguinal hernia, and torsion.
A supernumerary testicle is usually small.

Scrotal Pathology

Torsion, appendages, fluid collections, trauma, varicocele, inflammation (epididymitis, orchitis, epididymo-orchitis), microlithiasis, and masses are all possible scrotal pathologies.

Torsion

Interruption of testicular blood supply due to spermatic cord twisting is called torsion.
Bell clapper deformity is a common cause of torsion. This is when the tunica vaginalis completely surrounds the testis, epididymis, and distal spermatic cord, allowing movement and rotation within the scrotum.
Torsion is more frequent during adolescence (12-18 years).
Venous flow is initially affected creating scrotal swelling.
Loss of arterial flow and testicular ischemia eventually develop with continuation of torsion.
A 360-degree torsion affects all testicular blood vessels.
Torsion is a surgical emergency. Prompt surgical intervention within 6 hours of pain onset results in 80% to 100% testicular salvage (saving the testis).
Between 6-12 hours salvage rate is 70%, and after 12 hours only 20% are saved. Salvageability is generally not possible after 24 hours.
Clinical signs include acute onset pain (often during sleep), possible lower abdominal or inguinal pain, swollen testis/scrotum, nausea, vomiting, and malposition of the testicle.
Enlarged spermatic cord, epididymis, and testicle, lack of intratesticular blood flow, and hypoechoic (low-level) heterogenous testicle are findings suggestive of torsion.
Hydrocele and a thick scrotal wall can also occur.

Appendages

Embryologic remnants of tissue, primarily from the testis or epididymis, are considered appendages.
Appendages can undergo torsion causing scrotal pain, most commonly in prepubertal boys.
A "blue-dot sign" implies appendix torsion. A calcified, mobile appendix is a scrotal pearl.

Fluid Collections

Fluid collections occur in a potential space between visceral and parietal tunica vaginalis layers.
Common conditions in this space include hydrocele, pyocele, and hematocele.

Hydrocele

Serous fluid accumulation creates a hydrocele, usually a painless scrotal swelling.
Idiopathic (no identified cause) or associated with epididymo-orchitis and torsion.

Pyocele

Purulent (pus) fluid accumulation forms a pyocele.
Pyocele develops when an untreated infection or an abscess ruptures into the tunica vaginalis.

Hematocele

Blood collection is a hematocele caused by trauma.
Sonographic appearance varies with injury age. Initially, a hematocele shows numerous, highly visible, movable echoes. In time, it becomes hypoechoic with fluid-fluid levels and internal septations.

Acute Scrotum

Scrotal trauma, frequently resulting from motor vehicle accidents, athletic injuries, or straddle injuries; painful and often swollen scrotum.
Possible testicular rupture.

Testicular Rupture/Fracture

Focal alteration of testicular parenchyma, interruption of the tunica albuginea, irregular testicular contour, and scrotal wall thickening on ultrasound can suggest testicular rupture.
Blood flow disruption across the surface of the testis, and the presence of a hematocele are also indicative.
Prompt surgical intervention (within 72 hours) can improve the chances of testicular salvage (up to 90%). Salvage is less common after 72 hours (only 45%).

Hematoma

Hematomas can be related to trauma, may be large, resulting in testicular displacement.
Hematomas appear as heterogeneous areas within the scrotum. Over time, these areas may become more complicated, creating cystic components. Hematomas can involve the testis or epididymis, or they may be contained within the scrotal wall.

Varicocele

An abnormal dilation of pampiniform plexus veins.
Most common cause of treatable male infertility.
More frequent in the left testicle.
Primary varicocele arises from incompetent venous valves of the spermatic vein or pampiniform plexus, often found on the left side. Nutcracker syndrome may also cause one.
Secondary varicocele is related to increased pressure in the spermatic vein resulting from conditions including hydronephrosis, hepatomegaly, cirrhosis or other retroperitoneal/abdominal masses.
Typical symptoms are typically painless, but a palpable extratesticular mass ("bag of worms") may be present.
Infertility may also be a symptom..
Sonography shows numerous, anechoic, tortuous tubes (varicose veins) outside the testicle
The size and shape of varix changes in response to Valsalva maneuver. (Increased pressure, blood vessels fill)

Scrotal Inflammation

Inflammation of various scrotal structures (epididymis, testis, or both) leading to acute testicular pain. Factors include leukocytosis, fever, dysuria, urethral discharge, scrotal wall edema, and sexually transmitted diseases.

Epididymitis

Epididymitis is inflammation of the epididymis, the most common cause of acute scrotal pain in adults. The condition is frequently associated with sexually transmitted infections in younger men.
Enlarged, hypoechoic epididymis is an ultrasound sign, sometimes with focal or diffuse hyperemia (increased blood flow) seen on color Doppler procedures.

Epididymo-orchitis

Epididymo-orchitis involves the epididymis (inflammation of the epididymis) and the testis (inflammation of the testis).
Commonly related to the spread of lower urinary tract infection through the spermatic cord.
Ultrasound demonstrates signs of epididymitis (enlarged, hypoechoic epididymis) and with or without involvement of the testis, the presence of hyperemia and thickened scrotal wall.
An infrequent complication, pyocele, might be present in severe cases. This is characterized by pus accumulating between layers of tunica vaginalis.

Microlithiasis

Numerous echogenic foci (structures giving high level echoes) without acoustic shadowing in the testis are characteristic of microlithiasis.
Microcalcifications commonly are less than 3 millimeters.
Microlithiasis often appears bilaterally.
Increased risk of testicular cancer is associated with the complication, although the exact cause is unknown. Conditions such as Cryptorchidism, Klinefelter syndrome, infertility, varicoceles, testicular atrophy, and male pseudohermaphroditism are also common.

Extratesticular Masses

Most scrotal cysts are extratesticular, typically within the tunica albuginea or epididymis.
Common extratesticular masses include spermatoceles (cystic dilatations of the efferent ductules of the epididymis, often within the head), epididymal cysts, and tunica albuginea cysts.
Many extratesticular masses are asymptomatic, but some may be palpable.

Spermatoceles

Cystic dilatations of efferent ductules of the epididymis, commonly within the epididymal head.
They often contain proteinaceous fluid and nonviable sperm.
They may be seen more frequently following a vasectomy.

Epididymal Cysts

Small, clear cysts situated within the epididymis, containing serous fluid.

Tunica Albuginea Cysts

Present anywhere along the periphery of the testicle within the tunica albuginea.

Scrotal Hernia

Scrotal hernias (inguinal hernias) occur when a part of the bowel, omentum, or other structures passes through the inguinal canal and into the scrotum.
A clinical diagnosis is often sufficient, including examination. However, ultrasound is sometimes helpful for unclear cases.
Bowel is the most common herniated structure, followed by the omentum.

Tubular Ectasia

Cystic enlargement of the rete testis is tubular ectasia. The rete testis is located at the hilum of the testis within the mediastinum.
It is an uncommon, benign condition.
Associated conditions include spermatoceles, epididymal/testicular cysts, or epididymal obstructions on the same side of dilation.

Intratesticular Cysts

Intratesticular cysts (cysts within the testis) are more frequent in men over forty. These lesions are typically linked with spermatoceles.
They frequently present near the mediastinum, either as a singular cyst or multiple cysts of various sizes.

Sperm Granuloma

Inflammation reaction to extravasation of spermatozoa (sperm leakage) forms a sperm granuloma.
Most commonly found in vasectomy patients.
A sperm granuloma may develop anywhere within the epididymis or vas deferens.

Adrenal Rests

Ectopic adrenal tissue within the testicle; migrates during fetal development.
Clinical signs include congenital adrenal hyperplasia, elevated adrenocorticotropic hormone (ACTH), and possible Cushing syndrome.
The sonographic appearance shows bilateral, round, hypoechoic intratesticular masses that frequently lie near the mediastinum.

Testicular Carcinoma

Uncommon cancer, categorized as germ cell or non-germ cell tumors.
Highly curable form of cancer.
Most frequent between ages 20-34.
Symptoms include painless lumps, testicular enlargement, or vague scrotal discomfort.
Extratesticular masses are usually benign. Intratesticular masses, however, are more likely malignant until proven otherwise.

Germ Cell Tumors

95% of testicular tumors are categorized as germ cell tumors.
Often highly malignant, they are associated with elevated levels of human chorionic gonadotropin (hCG) and alpha-fetoprotein (AFP).
Subtypes include seminoma, teratoma, embryonal cell carcinoma, yolk sac tumor, and choriocarcinoma.

Seminoma

Most common testicular germ cell malignancy, typically in males aged 30-50.
Clinical signs often include asymptomatic painless scrotal mass, hardening of the testicle, and possibly elevated levels of human chorionic gonadotropin (hCG).
Sonographic findings are frequently solid, hypoechoic, intratesticular masses. They can exhibit heterogeneity if large.

Teratoma

Benign tumor, with inherent potential for malignancy.
Symptoms may include palpable mass, and possible elevated levels of alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) if malignant.
A heterogeneous mass with calcifications, bone, teeth, cartilage, and hair, is frequent on imaging.

Embryonal Cell Carcinoma

More aggressive than seminoma.
May be palpable and possibly elevated levels of alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG).
Appearance on ultrasound is heterogeneous, with cystic components and increased echogenicity due to possible calcifications, hemorrhage, and fibrosis.

Yolk Sac Tumor

Rare, with a good prognosis.
Signs may include palpable testicular masses, and raised levels of alpha-fetoprotein (AFP) alone.
Image characteristics: heterogeneous, with areas of bleeding and calcification.

Choriocarcinoma

Rare, aggressive tumor.
May be palpable and elevated levels of human chorionic gonadotropin (hCG) are common.
A varied ultrasound appearance is characteristic, arising from mixed cell types. There is frequently a heterogeneous mass with areas of hemorrhage, necrosis, and calcifications. Irregular borders are also common.

Non-Germ Cell Tumors

Usually seen in younger boys, non-germ cell tumors include sex cord-stromal tumors, lymphoma, leukemia, and metastases..

Leydig Cell Tumor

An uncommon tumor, it is often associated with increased testosterone levels and virilization.
Sonographically, small and hypoechoic intratesticular masses are common, possibly including cystic areas.

Sertoli Cell Tumor

An extremely rare tumor, it produces estrogen, resulting in gynecomastia (breast enlargement in males).
Sonographic findings frequently include a hypoechoic, hypervascular intratesticular mass.

Granulosa Cell Tumor

A rare condition associated with chromosomal abnormalities.
Elevated levels of estrogen are common, including gynecomastia.
Sonograms typically demonstrate hypoechogenicity and hypervascular appearance.

Lymphoma and Leukemia

Malignant lymphoma (1-7% of testicular cancers) is often bilateral in testicular cases.
Leukemia often is the next most common secondary testicular neoplasm in children.
Ultrasound findings might reveal testicular enlargement that spreads to a bilateral (or unilateral) tumor.

Metastasis

Rare, usually occurs later in life.
Tumors from prostate or kidneys are common origins of metastases to the testicles.
Other potential origins include lung, pancreas, bladder, colon, thyroid, or melanoma.
Ultrasound typically shows bilateral metastases and multiple lesions. Appearance includes hyperechoic, solid hypoechoic masses, or a mixed pattern.

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Description

Test your knowledge on the sonographic appearances and findings associated with testicular trauma and conditions such as hematocele, scrotal rupture, and cryptorchidism. This quiz covers key characteristics, evaluation time limits for surgery, and ultrasound assessments for male infertility. Discover how well you understand the nuances of scrotal ultrasound diagnostics.